Provider Demographics
NPI:1639657471
Name:TEJEDA-RODRIGUEZ, IDALBERTO JESUS
Entity Type:Individual
Prefix:
First Name:IDALBERTO
Middle Name:JESUS
Last Name:TEJEDA-RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 SW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:COCONUT GROVE
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2728
Mailing Address - Country:US
Mailing Address - Phone:305-642-4263
Mailing Address - Fax:305-426-3329
Practice Address - Street 1:2001 SW 67TH AVE APT 2-317
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1824
Practice Address - Country:US
Practice Address - Phone:786-451-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9437269363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9437269OtherARNP